CalPERS Medicare Enrollment Guide

Transcription

1 CalPERS Medicare Enrollment Guide A practical guide to understanding how CalPERS and Medicare work together Information as of August 2015

2 About CalPERS CalPERS is the largest purchaser of public employee health benefits in California, and the second largest public purchaser in the nation after the federal government. Our program provides benefits to more than 1.3 million public employees, retirees, and their families. At CalPERS, we understand that making decisions about your health care can be a complex and important process. We have designed this publication to help you understand how your Medicare benefits work with your CalPERS health benefits. Depending on where you reside or work, your health plan options may include: Health Maintenance Organization (HMO) Preferred Provider Organization (PPO) Exclusive Provider Organization (EPO) (for members in certain California counties) Each type of plan works with Medicare to provide health coverage. Whether you are working or retired, your employer or former employer may make a monthly contribution toward your health premium. The amount of this contribution varies. Your cost will depend on your employer or former employer s contribution, the length of your employment, the health plan you choose, and whether you are enrolled in Medicare Parts A and B. To find out the monthly contribution amounts, active employees should contact their employer, State retirees should contact CalPERS, and contracting agency retirees should contact their former employer. CalPERS Health Program Vision Statement CalPERS will lead in the promotion of health and wellness of our members through best-in-class, data-driven, cost-effective, quality, and sustainable health benefit options for our members and employers. We will engage our members, employers, and other stakeholders as active partners in this pursuit and be a leader for health care reform both in California and nationally.

3 About This Publication The CalPERS Medicare Enrollment Guide provides information about how Medicare works with your CalPERS health benefits. (See page 5 for a description of the different parts of Medicare.) For eligibility information and an explanation of when you need to enroll in a CalPERS Medicare health plan, see page 8. This publication is one of many resources CalPERS offers to help you choose and use your health plan. Others include: Health Benefit Summary Provides valuable information to help you make an informed choice about your health plan; compares benefits, covered services, and co-payment information for all CalPERS health plans Health Program Guide Describes Basic and Medicare health plan eligibility, enrollment, and choices You can obtain the above publications and other information about your CalPERS health benefits through the CalPERS website at or by calling CalPERS at 888 CalPERS (or ). CalPERS Medicare Enrollment Guide 1

4 Where to Get Help With Your Health Benefits Enrollment Once you retire, CalPERS becomes your Health Benefits Offcer. Contact CalPERS directly to make all health benefit enrollment changes. You may call us toll free at 888 CalPERS (or ) or write to us at P.O. Box , Sacramento, CA for assistance. If you are working, contact your employer s Health Benefits Offcer to make all health benefit enrollment changes. 2 CalPERS Medicare Enrollment Guide

5 Contents Understanding Medicare Medicare Part A (Hospital) Medicare Part B (Medical) Medicare Part C (Medicare Advantage Health Plans) Medicare Part D (Prescription Drug) When to Enroll in a CalPERS Medicare Health Plan Eligibility Guidelines for CalPERS Medicare Health Plans Certifying Your Medicare Status CalPERS Medicare Health Plan Enrollment Exceptions Continuing to Work After Retirement CalPERS Medicare Health Plan Options HMO Medicare Managed Care Plans (Medicare Advantage Health Plans). 17 Medicare Advantage PPO Plan PPO Supplement to Medicare Plans EPO Supplement to Medicare Plan COBRA Continuation Coverage Health Coverage if You Travel or Reside Outside the United States Changing Your CalPERS Medicare Health Plan Medicare Part B Reimbursement for State and CSU Retirees Frequently Asked Questions About Medicare and the CalPERS Health Program Resources Getting Assistance with Your Health Benefits Contacting Your Health Plan Obtaining Additional Medicare Information Resolving Problems with Your Health Plan Patient Bill of Rights CalPERS Notice of Privacy Practices Definition of Terms CalPERS Medicare Enrollment Guide 3

6 Understanding Medicare Medicare is a federal health insurance program for individuals: Age 65 and older Under age 65 with certain Social Security-qualified disabilities With End-Stage Renal Disease (ESRD) The Social Security Administration (SSA) is the federal agency responsible for Medicare eligibility determination, enrollment, and premiums. The Centers for Medicare & Medicaid Services (CMS) regulates the Medicare program. The CMS publishes Medicare & You, a handbook that provides general information about Medicare. You can view or download this publication at Medicare covers specific services if you meet certain conditions. The following section provides basic information about the parts of Medicare, which will help you understand eligibility guidelines and enrollment in your CalPERS health plan. For more information about Medicare benefits, premiums, enrollment, and eligibility issues, contact the SSA at (800) or TTY (800) , or visit their website at 4 CalPERS Medicare Enrollment Guide

7 Medicare Part A (Hospital) Medicare Part A is hospital insurance that helps pay for inpatient hospital stays, skilled nursing facilities, hospice care, and some home health care. You or your dependents may become eligible for premium-free Medicare Part A in one of the following ways: If you are age 65 or older and you have worked for at least 10 years (40 quarters) in Social Security/Medicare-covered employment. Through the work history of a current, former, or deceased spouse. If you have ESRD or a Social Security-qualified disability and meet certain SSA requirements. If you do not qualify for premium-free Medicare Part A, you may pay a premium to receive Medicare Part A. You also may be subject to a late enrollment penalty if you fail to apply for Medicare Part A when you first become eligible. Medicare Part B (Medical) Medicare Part B is medical insurance that helps pay for outpatient health care expenses, including doctor visits. The SSA bases your Part B premium on your annual income. If your income exceeds established thresholds, the SSA adjusts the standard Medicare Part B premium by an income-related monthly adjustment amount. Payment of this amount is mandatory to protect your eligibility to remain enrolled in a CalPERS Medicare health plan. Following are two important notes about Medicare Part B: When you turn 65, you qualify for Medicare Part B. In some cases, you may qualify if you are under age 65. If you do not sign up for Medicare Part B when you first qualify, you can sign up later, but you will be subject to the federal late enrollment penalty and your premium will be higher. CalPERS Medicare Enrollment Guide 5

8 If you are receiving SSA benefits, the additional premium will be deducted from your Social Security benefits. If not, you will be billed quarterly. If you disagree with the amount indicated, contact the SSA toll free at (800) or TTY (800) , or visit their website at Note: If you are retired and you or your dependents are eligible for Medicare Part A at no cost, CalPERS requires that you or your eligible dependent enroll in Medicare Part B. CalPERS does not require that you enroll in Medicare Parts A and B until you or your dependents become eligible for Medicare Part A at no cost. Medicare Part C (Medicare Advantage Health Plans) Medicare Part C is a CMS-approved health coverage option that is provided by private insurance under contract with CMS. These Medicare Managed Care plans are also referred to as Medicare Advantage plans. For additional information refer to page 17. Medicare Part D (Prescription Drug) Medicare Part D is a voluntary federal outpatient prescription drug benefit available to everyone with Medicare. The Medicare Part D premium varies based on the prescription drug plan and is paid to your health carrier as part of the CalPERS health premium. As with Medicare Part B, if your income exceeds established thresholds, the SSA will assess an additional incomerelated monthly adjustment amount. Payment of this amount is mandatory to protect your Medicare enrollment and eligibility to remain enrolled in a CalPERS Medicare health plan. 6 CalPERS Medicare Enrollment Guide

9 If you are receiving SSA benefits, the additional premium will be deducted from your Social Security benefits. If not, you will be billed quarterly. If you disagree with the amount indicated, contact the SSA toll free at (800) or TTY (800) , or visit their website at Note: To be enrolled in a CalPERS Medicare health plan, you cannot be enrolled in a non-calpers Medicare Part D plan. Medicare Enrollment Periods SSA has specific deadlines for enrolling in Medicare. For details, please refer to the Medicare & You handbook published by CMS and available at or contact SSA toll free at (800) CalPERS Medicare Enrollment Guide 7

10 When to Enroll in a CalPERS Medicare Health Plan Medicare Parts A and B provide coverage for many of your health care costs; however, Medicare does not pay all costs. CalPERS Medicare health plans coordinate with the Medicare program to help pay costs not covered by Medicare. If you (and your dependents) are enrolled in a CalPERS Basic health plan when you retire and become Medicare eligible, you must first enroll in Medicare Parts A and B. You must then transfer to a CalPERS Medicare health plan to continue your CalPERS coverage. Eligibility Guidelines for CalPERS Medicare Health Plans If you are currently enrolled in a CalPERS Basic health plan, you or your dependents are eligible to enroll in a CalPERS Medicare health plan under any of the following circumstances: You are age 65 or older at retirement and eligible for Medicare Parts A and B in your own right or through the work history of a current, former, or deceased spouse You (or your dependents) are any age, have End-Stage Renal Disease (ESRD), and the 30-month Social Security coordination period has been completed You are retired and you (or your dependents) have a Social Securityqualified disability and the 24-month Social Security coordination period has been completed 8 CalPERS Medicare Enrollment Guide

11 You are retired from a California State Teachers Retirement System (CalSTRS) employer and are eligible for the CalSTRS Medicare Premium Payment Program. For more details, see page 14 of this booklet, visit or call CalSTRS toll free at (800) Certifying Your Medicare Status You will receive a notice from CalPERS four months prior to the month you turn 65. This notice informs you of CalPERS requirements to continue your health coverage. If you are retired or have initiated the process of retiring from active employment, you will also receive a Certification of Medicare Status form along with this notice. CalPERS requires that you complete this form and provide proof of your Medicare status. You must certify your Medicare status in order to continue your CalPERS health coverage. Complete and return the Certification of Medicare Status form to CalPERS with documentation certifying one of the following choices: Enrollment in Medicare Parts A and B (submit a copy of Medicare card or SSA documentation) Ineligible for Medicare either in your own right and/or through the work history of a current, former, or deceased spouse (submit SSA documentation) Deferred enrollment in Medicare Part B due to your or your spouse s employment (submit proof of active group health insurance through current employer) If you are retired, and you do not return the Certification of Medicare Status form and/or copies of your supporting documentation to CalPERS by the beginning of your birth month, you will receive a notice of cancellation informing you that health coverage for yourself and all enrolled dependents will be automatically canceled the first day of the month after you turn 65. If you need assistance completing the form, contact CalPERS toll free at 888 CalPERS (or ). CalPERS Medicare Enrollment Guide 9

12 Note: Your CalPERS Medicare health plan will become effective on your Medicare effective date or the first day of the month following CalPERS receipt of the Certification of Medicare Status form, whichever is later. Ineligible for Medicare If you are ineligible for Medicare, you must indicate on the Certification of Medicare Status form the reason for your ineligibility: Did not work in employment covered by Social Security/Medicare Do not have 40 quarters in Social Security/Medicare-covered employment Do not qualify through the work history of a current, former, or deceased spouse When you return the Certification of Medicare Status form, you must submit a copy of the Social Security statement or letter from the SSA indicating that you are not eligible for Medicare based on your work record and/or the work history of a current, former, or deceased spouse. You may remain in a Basic health plan until you later become eligible for Medicare Part A at no cost. Not Qualified for Medicare Part A If you do not qualify for premium-free Medicare Part A based on your Social Security/Medicare work record or the record of your current, former, or deceased spouse, you may remain in a CalPERS Basic health plan. If you later qualify for Medicare Part A at no cost, you must enroll in Medicare Part B and in a CalPERS Medicare health plan. If you are a CalSTRS retiree, and need to determine your eligibility for their Medicare Premium Payment Program, contact CalSTRS toll free at (800) CalPERS Medicare Enrollment Guide

13 Note: If you are not currently eligible for premium-free Medicare Part A in your own right, you may be eligible for it when your spouse turns 62. To find out if you are eligible through a spouse, contact the SSA at (800) or TTY (800) , or visit their website at Deferred Enrollment in Medicare Part B You or your spouse can defer enrollment in Medicare Part B if either of the following apply: You are still working and have active employer group health coverage Your spouse is still working and you are covered under his or her active employer group health coverage If you are deferring enrollment in Medicare Part B, you must indicate this on the Certification of Medicare Status form. Return the form to CalPERS, and provide proof of active group health insurance through the current employer. You will remain in a CalPERS Basic health plan until retirement or until you lose your employer group health coverage. Note: The option to defer your enrollment in Part B does not apply to workers in the California State University (CSU) System Faculty Early Retirement Program (FERP). If you are working under a FERP contract and are eligible for Medicare Part A at no cost, you must enroll in Medicare to retain your CalPERS health coverage. Cancellation of CalPERS Health Coverage for Failure to Certify Medicare Status If your CalPERS Basic health plan coverage is canceled because you did not provide your Medicare status to CalPERS, you can request re-enrollment through an Administrative Review process within 90 days of the date the coverage is canceled by writing to: CalPERS Health Account Services Medicare Administration P.O. Box Sacramento, CA CalPERS Medicare Enrollment Guide 11

14 You will receive a determination within 60 days informing you if your coverage will be reinstated. If your coverage is not reinstated, you may re-enroll during CalPERS annual Open Enrollment period by providing a completed Certification of Medicare Status form with the required supporting documentation. CalPERS Health Plans and Medicare Part D CalPERS participates in the Employer Group Waiver Plan (EGWP). EGWPs are Prescription Drug Plans governed by the CMS. If you are a Medicare-eligible subscriber or dependent, you are automatically enrolled into EGWP. Your residential address is required to complete the automatic enrollment process. CMS does not permit a Post Offce Box as a permanent address. If for some reason, you chose to opt out of EGWP, you will be financially responsible for all of your prescription drug costs. In addition, if you enroll in a non-calpers Medicare Part D plan, you are no longer eligible to remain enrolled in a CalPERS Medicare health plan. Consequently, you and all of your covered dependents will be terminated. Do Not Enroll in a non-calpers Medicare Part D Plan Your CalPERS coverage includes enrollment in a Medicare Part D Plan. Do not enroll in a non-calpers Medicare Part D plan. If you or your dependents are covered by CalPERS and another health plan that includes Medicare Part D prescription drug benefits, you must cancel that Part D coverage to enroll in, or continue enrollment in a CalPERS Medicare health plan. 12 CalPERS Medicare Enrollment Guide

15 CalPERS Medicare Health Plan Enrollment Exceptions Following are examples of circumstances that may allow you to remain enrolled in a CalPERS Basic health plan: Neither you nor your spouse qualifies for Medicare Part A at no cost. You or your spouse works past age 65 and has employer group health coverage. You were eligible for Medicare Parts A and B before January 1, 1998, but you did not enroll in Part B. You retired from the California State University (CSU) system and qualified for Medicare Parts A and B before January 1, 2001, but you did not enroll in Part B. (This does not apply to participants in the CSU system s FERP.) You were eligible for Medicare because of a disability, but the SSA determined you are no longer disabled and you no longer qualify for premium-free Medicare Part A. You move permanently outside of the United States. Return the Certification of Medicare Status Form If you do not return the Certification of Medicare Status form with the proper documentation prior to the last day of the month you turn 65, your CalPERS health coverage will automatically be canceled the first day of the month after you turn 65. CalPERS Medicare Enrollment Guide 13

16 Enroll in a CalPERS Medicare Health Plan At Retirement Three months before you turn 65, apply for Medicare by contacting the SSA toll free at (800) or TTY (800) , or visiting a SSA Offce. Be prepared to provide your and your spouse s Social Security numbers. If you qualify for Medicare Part A at no cost, you must enroll in Medicare Part B as soon as you are first eligible. If you are a CalSTRS retiree, contact CalSTRS to determine your eligibility for the CalSTRS Medicare Premium Payment Program. Prior to the first day of the month you turn 65, complete and return the CalPERS Certification of Medicare Status form along with a copy of your supporting documentation. You may select a Medicare health plan that is different from your current Basic health plan. Moving Contact your health plan and CalPERS if you move. Medicare health plans have specific rules associated with changing health plans due to a move. Notifying CalPERS of your change of address and inquiring about whether changes need to occur because of your move will allow for a smooth transition of your health coverage. 14 CalPERS Medicare Enrollment Guide

17 Continuing to Work After Retirement If you choose to work following retirement from CalPERS employment, your options depend upon whether you or your spouse is covered by an employer group health plan based on the active employment. You Do Not Have Employer Group Health Coverage If you work following retirement but do not have employer group health coverage (your own or your spouse s) from that employment you may continue your CalPERS health coverage, by certifying your Medicare status. If eligible for Medicare, you must choose a CalPERS Medicare health plan available for your residential address. You Have Employer Group Health Coverage If you choose to work following retirement and have employer group health coverage through your current employer (your own or your spouse s), you may enroll in Medicare Parts A and/or B, and remain enrolled in a CalPERS Basic health plan. Your employer group health plan will be your primary coverage and your Medicare benefits secondary. You may defer enrollment in Medicare, and remain in a CalPERS Basic health plan as long as you are working and have employer group health coverage through your current employment. When you retire or lose employer group coverage, immediately enroll in Medicare Part B and contact CalPERS to transition into a CalPERS Medicare plan. Note for CalSTRS Retirees If you do not qualify for premium-free Medicare Part A, please contact CalSTRS about their Medicare Premium Payment Program to determine if you can obtain Medicare Part A at no cost. To determine your eligibility for this program, visit or call (800) CalPERS Medicare Enrollment Guide 15

18 CalPERS Medicare Health Plan Options CalPERS offers several Medicare health plans. When you retire, become Medicare eligible and provide proof of enrollment in Medicare Parts A and B, CalPERS will enroll you in a Medicare health plan of your choice. Combination Enrollments If you or a dependent enroll in a CalPERS Medicare health plan, non-medicare eligible enrollees (yourself or a dependent) will remain in a CalPERS Basic health plan. You may make changes to your health plan in any of the following ways: Through my CalPERS at my.calpers.ca.gov when you turn age 65 or during Open Enrollment By completing a Health Benefits Plan Enrollment form and mailing it to CalPERS at P.O. Box , Sacramento, CA, or faxing it to (800) By calling CalPERS toll free at 888 CalPERS (or ) To compare benefits across plans, refer to the Health Benefit Summary available at the CalPERS website at or by calling CalPERS toll free at 888 CalPERS (or ). You can also check the availability of health plans in a specific ZIP Code on the CalPERS website at through my CalPERS at my.calpers.ca.gov, or by calling CalPERS toll free at 888 CalPERS (or ). 16 CalPERS Medicare Enrollment Guide

19 HMO Medicare Managed Care Plans (Medicare Advantage Health Plans) With an HMO Medicare Managed Care (Medicare Advantage) plan, you work closely with your PCP to get the care you need. You pay no additional costs, other than applicable co-payments, when you receive services from the HMO s network of providers. If you go to out-of-network doctors or hospitals, you will have to pay for all services (except for emergency or out-of-area urgent care services). A Medicare Managed Care plan has been approved by the Medicare program and receives a monthly premium directly from Medicare to provide your Medicare benefits. Medicare Advantage plans are geographically restricted. To enroll in a Medicare Advantage plan, you must reside within the health plan s service area. When enrolling in a Medicare Advantage plan, you must also assign your Medicare benefits by completing the plan s Medicare Advantage Election form. Note: If you choose to change to a different plan, you must contact your current plan to disenroll from the Medicare Advantage plan. The plan cannot release your Medicare benefits to another plan without your request to disenroll. CalPERS Medicare Enrollment Guide 17

20 HMO and Medicare Advantage Requirements HMO and Medicare Advantage plans are geographically restricted. When enrolling in these plans, you must provide your residential address to enroll. Enrolling in a CalPERS Medicare Advantage Plan Enroll in Medicare Parts A and B. Submit the Certification for Medicare Status form and supporting documents to CalPERS. Complete the plan s Medicare Advantage Election form to allow the plan to administer your Medicare benefits. Use your residential address when enrolling. Note: CMS regulations do not allow you to enroll in a Medicare Advantage plan through more than one employer. This type of double coverage frequently happens when a member has coverage through CalPERS in addition to an outside source. You must choose one employer with whom to continue enrollment. Medicare Advantage PPO Plan Medicare Advantage PPO Plan includes Medicare health benefits in all 58 counties in California, as well as all of the U.S., and five U.S. territories. Members have access to all providers that accept Medicare. No Primary Care Physician (PCP) selection required, no referrals required to see a specialist, and there is no annual deductible. 18 CalPERS Medicare Enrollment Guide

21 PPO Supplement to Medicare Plans With a Preferred Provider Organization (PPO) Supplement to Medicare plan, your provider bills Medicare for most services and your health plan pays for some services not covered by Medicare. If your providers participate in Medicare, your health plan will pay most bills for Medicare-approved services. In most cases, your provider, Medicare, and the health plan will coordinate claim payments. If any of your providers do not accept Medicare payments directly, you will have to pay a larger portion of your health care bills. You can find out if you will have to pay more by asking your providers if they accept Medicare direct payment. This means that the provider accepts the Medicare limits on fees for services and will not charge more than those limits. If the provider accepts Medicare rates, you will not be responsible for excess charges. If the provider does not accept Medicare rates, you must pay for any part of the bill that your plan does not cover. Some providers opt out of Medicare and will ask you to sign a contract stating that the provider has opted out of Medicare and that you agree to pay the charges. Neither Medicare nor CalPERS PPO Supplement to Medicare plans allow any payment for providers who have opted out of Medicare. If your provider has been excluded from Medicare (i.e., your provider no longer receives payment for items or services from Medicare), no payment will be made under your CalPERS PPO Supplement to Medicare plan. CalPERS Medicare Enrollment Guide 19

22 EPO Supplement to Medicare Plan The Exclusive Provider Organization (EPO) Supplement to Medicare plan serves only Colusa, Mendocino, and Sierra counties. This plan offers the same covered services as the HMO plan, but members must seek services from the plan s statewide preferred provider network. Members in an EPO plan are not required to select a primary care provider. The plan s providers bill Medicare for each visit or service, and the plan reimburses providers for approved services not covered by Medicare. Just as with an HMO Supplement to Medicare plan, you may use your Medicare card to obtain services outside your EPO plan s network. However, when you use non-contracting providers, you are responsible for co-payments or deductibles not covered by Medicare. COBRA Continuation Coverage If you lose your CalPERS health coverage due to certain qualifying events, the Consolidated Omnibus Budget Reconciliation Act (COBRA) Continuation Coverage allows you to continue health coverage for yourself and/or your dependents. Following are some guidelines regarding COBRA and Medicare: If you have Medicare eligibility prior to electing COBRA, you may continue health coverage through COBRA. If you become Medicare eligible after you elect COBRA, the health plan can cancel your COBRA enrollment. If you are a family member, you may continue your COBRA Basic coverage for whatever time remains on your COBRA eligibility, or until you become Medicare eligible. 20 CalPERS Medicare Enrollment Guide

23 Health Coverage if You Travel or Reside Outside the United States Traveling If you are retired and you travel outside of your health plan service area, contact your health plan to determine available coverage. You should be aware that Medicare generally does not provide coverage for health care services obtained outside the United States. You may also contact CMS to obtain information about your health coverage options while traveling outside the United States. Residing Outside the United States If you are retired and permanently reside outside the United States, you may enroll in one of the CalPERS PPO Basic health plans that provides coverage outside the United States. Contact CalPERS for information about which plans provide such coverage. Note: Medicare does not provide coverage for health care services obtained outside the United States. To ensure continued health care coverage if you return to the United States, you may maintain your Medicare Part B enrollment. If you choose to cancel your Medicare Part B, you may have a penalty assessed on your Medicare Part B premium when you re-enroll with SSA. You may also have a disruption of coverage with your CalPERS insurance. To re-enroll in a CalPERS Medicare health plan when you re-establish permanent residence in the United States, provide CalPERS the following: Proof of Medicare Part B re-enrollment Change of address information for your new United States address To re-enroll in Medicare Part B, contact SSA at (800) or TTY (800) , or visit their website at You may also contact CMS toll free at (800) or visit their website at CalPERS Medicare Enrollment Guide 21

24 Changing Your CalPERS Medicare Health Plan You may request a change in health plans at the following times: During any CalPERS Open Enrollment period Within 60 days of the following events: Your retirement Enrollment in Medicare by you or your dependents Change in your residence or a move to a new health plan service area CalPERS Open Enrollment is held annually during the fall. If you wish to enroll in a health plan, change health plans, or add/delete eligible dependents during Open Enrollment, visit the CalPERS website at or use my CalPERS at my.calpers.ca.gov to make any changes. Plan changes you make during Open Enrollment become effective January 1 of the following year. Changing from a Medicare Plan to a Basic Plan If you or your dependents are in a CalPERS Medicare health plan, you may only change back to a CalPERS Basic plan if: You permanently move outside the United States You return to work and are eligible for employer group health coverage The SSA cancels your Medicare benefits for reasons other than non-payment or by your request 22 CalPERS Medicare Enrollment Guide

25 Medicare Part B Reimbursement for State and CSU Retirees The SSA establishes Medicare Part B premiums annually. If you are a State of California or CSU retiree and you or your dependents are enrolled in a CalPERS Medicare health plan, you may be entitled to a reimbursement of your Medicare Part B premium. CalPERS will automatically reimburse all or part of your premium, up to the minimum standard Medicare Part B premium. Under California law, the Part B reimbursement may not exceed the difference between the maximum employer contribution and the premium for the health plan in which you are enrolled. Following is a hypothetical situation that illustrates how a reimbursement works. The amount of her reimbursement is limited to $ Mary is enrolled in a CalPERS Medicare health plan and has no dependents. Her State employer health plan contribution is $450 per month, and her health plan premium is $350 per month. After her health plan premium is paid, Mary has $100 of her employer contribution remaining to apply to her Medicare Part B premium ($450 $350 = $100). If Mary s income exceeds Medicare income thresholds, she will be subject to an income-related monthly adjustment amount, and her Medicare Part B premium will be higher than the minimum standard rate. In that case, she could request additional income-related Medicare Part B premium reimbursement by submitting a copy of her Social Security benefits notice to CalPERS. Her total reimbursement cannot exceed the difference between her employer contribution and the total premium. Depending on current SSA requirements, some members who are not subject to an income-related monthly adjustment amount may be required by SSA to pay a Part B premium that is higher than the minimum standard rate. Note: California law does not provide for reimbursement of Medicare Part B premiums for retirees of contracting public agencies. You may contact your former employer to ask if this benefit is provided for you. CalPERS Medicare Enrollment Guide 23

26 Qualifying for Additional Reimbursement If you are a State of California or CSU retiree and you are paying more than the minimum standard Part B premium, you may qualify for an additional reimbursement. To apply, you must mail or fax a copy of your entire Social Security benefits notice to: CalPERS Health Account Services Medicare Administration P.O. Box Sacramento, CA Fax: (800) Note: For the current minimum standard Part B premium, contact SSA at (800) or TTY (800) , or at their website at 24 CalPERS Medicare Enrollment Guide

27 Frequently Asked Questions About Medicare and the CalPERS Health Program QQ: I am under 65 and have an SSA-qualified disability. Do I need to enroll in a CalPERS Medicare health plan? A: If you are under age 65, retired, and have an SSA-qualified disability, you must enroll in a CalPERS Medicare health plan once you have completed the 24-month SSA coordination period. To do so, if eligible, you must first apply for premium-free Medicare Part A and enroll in Medicare Part B. Once you enroll in Medicare, complete and send the Certification of Medicare Status form to CalPERS with a copy of your supporting documentation to ensure continuation of your CalPERS health coverage. QQ: If I have a dependent with an SSA-qualified disability, does my dependent need to enroll in a CalPERS Medicare health plan? A: If you are retired, your dependent with an SSA-qualified disability may be eligible to enroll in a CalPERS Medicare health plan once he or she has completed the 24-month SSA coordination period. If you are active, and you have a dependent with an SSA-qualified disability, your dependent is not eligible to enroll in a Medicare plan unless he or she has End-Stage Renal Disease (ESRD). You may enroll a dependent with ESRD in a Medicare plan after he or she completes the 30-month SSA coordination period. CalPERS Medicare Enrollment Guide 25

28 QQ: What happens if I cancel my Medicare Part B benefits? How will this affect my CalPERS Medicare plan? A: You must have Medicare Part B to continue your enrollment in a CalPERS Medicare health plan. If you request SSA to cancel your Part B coverage, or lose Part B because you stopped paying your premiums, you will lose your CalPERS health coverage. If the SSA cancels your Part B benefits for any reason, please inform CalPERS immediately. QQ: Since I must have Medicare Part B in order to keep my CalPERS health coverage, how does it help me to have Medicare Part B and be enrolled in a CalPERS Medicare health plan? A: CalPERS Medicare health plans may pay for some of the costs and services not covered by Medicare Part B. QQ: I am retired from the State of California and the monthly State contribution is more than the health plan s monthly premium. Can I get money back when I enroll in a CalPERS Medicare health plan? A: If you or your dependents are enrolled in a CalPERS Medicare health plan and the monthly State contribution is more than the health plan s monthly premium, CalPERS will reimburse you the difference (excluding penalties) between the two amounts up to the amount of the Part B premium. This reimbursement will show on your monthly retirement check. (See page 23 for an example of a Part B reimbursement.) Note: California law does not provide for reimbursement of Medicare Part B premiums for retirees of contracting public agencies. You may contact your former employer to ask if this benefit is provided for you. 26 CalPERS Medicare Enrollment Guide

29 QQ: I lost my CalPERS health benefits because I stopped my Medicare Part B. How can I get my CalPERS benefits back? A: Contact the SSA regarding reinstating your Medicare Part B benefits as soon as possible. You may have to pay a late enrollment penalty. You may request re-enrollment in a CalPERS Medicare plan after you provide documentation that your Medicare Part B benefits are reinstated. QQ: I am Medicare-eligible, but my spouse is still working, and I am covered under my spouse s active employer group health plan. When should I enroll in Medicare Part B? A: You have the option of enrolling in Medicare Part B while your employed spouse continues to work, or you may defer your Medicare Part B enrollment until your spouse retires or loses employer group health coverage. When either occurs, immediately enroll in Medicare Part B and contact CalPERS to transition to a CalPERS Medicare plan. QQ: How can I qualify for premium-free Part A? A: You may become eligible for premium-free Medicare Part A if you are age 65 or older and you have worked for at least 10 years (40 quarters) in Social Security/Medicare-covered employment. You may also qualify through the work history of a current, former, or deceased spouse, or if you have ESRD or a Social Security-qualified disability and meet certain SSA requirements. If you have questions about Medicare eligibility and enrollment, contact the SSA at (800) or TTY (800) , or visit their website at CalPERS Medicare Enrollment Guide 27

30 QQ: Before I retired, I was enrolled in a CalPERS Basic HMO plan. What do I need to do to change to the HMO s Medicare Managed Care plan? A: If you are already with the HMO and want to change to a Medicare Managed Care (Medicare Advantage) plan, contact the plan directly to request the plan s Medicare Advantage Election form. (For more information on Medicare Managed Care plans, see page 17.) QQ: I am Medicare eligible, retired from CalPERS, and returning to work. Can I continue my CalPERS Basic health plan coverage? A: You may continue your enrollment in a CalPERS Basic health plan if you receive your health coverage through employment status and not as a retiree through retirement status. You may also remain enrolled in a CalPERS Basic health plan if you are eligible to defer your Medicare enrollment. You may be able to defer Medicare enrollment if you are Medicare eligible and are covered by an employer group health plan (your own or your spouse s). 28 CalPERS Medicare Enrollment Guide

31 Resources Getting Assistance with Your Health Benefits If you have questions about your CalPERS health benefits and are an active member, contact your employer s Health Benefits Offcer. If you are a retiree, contact CalPERS. Online For more information on health benefits and programs, visit the CalPERS website at To view your current health plan information, go to my.calpers.ca.gov. By Phone Call CalPERS toll free at 888 CalPERS (or ) Monday through Friday, 8:00 a.m. to 5:00 p.m. TTY (877) (for speech and hearing impaired) By Mail or Fax CalPERS Health Account Services P.O. Box Sacramento, CA Fax (800) CalPERS Medicare Enrollment Guide 29

32 In Person You can visit a Regional Offce at the following locations: Fresno Regional Offce 10 River Park Place East, Suite 230 Fresno, CA Glendale Regional Offce 655 North Central Avenue, Suite 1400 Glendale, CA Orange Regional Offce 500 North State College Boulevard, Suite 750 Orange, CA Sacramento Regional Offce 400 Q Street, Room 1820 Sacramento, CA San Bernardino Regional Offce 650 East Hospitality Lane, Suite 330 San Bernardino, CA San Diego Regional Offce 7676 Hazard Center Drive, Suite 350 San Diego, CA San Jose Regional Offce 181 Metro Drive, Suite 520 San Jose, CA Walnut Creek Regional Offce 1340 Treat Boulevard, Suite 200 Walnut Creek, CA CalPERS Medicare Enrollment Guide

33 Contacting Your Health Plan To obtain up-to-date contact information for the health plans, please refer to the Health Benefit Summary or go to the CalPERS website at ca.gov. Contact your health plan with questions about: identification cards; verification of provider participation; service area boundaries (covered ZIP Codes); or Individual Conversion Policies. Your plan benefits, deductibles, limitations, and exclusions are outlined in detail in your health plan s Evidence of Coverage booklet. You can obtain the Evidence of Coverage by contacting your health plan directly. Obtaining Additional Medicare Information California Department of Aging (916) TTY: (800) Centers for Medicare and Medicaid Services (CMS) (800) TTY: (877) Health Insurance Counseling and Advocacy Program (HICAP) (800) Social Security Administration (SSA) (800) TTY: (800) CalPERS Medicare Enrollment Guide 31

34 Resolving Problems with Your Health Plan Your health plan and CalPERS work together to ensure timely delivery of services for you and your family; however, disagreements may occur. You should contact your health plan first and then CalPERS to assist you in resolving any issues. Review the following information to see how your health plan and CalPERS are here to help. Cancellation of Your Coverage and CalPERS Administrative Review Process If CalPERS cancels your CalPERS health coverage, you can request an Administrative Review. The Administrative Review process helps us decide if your coverage should be reinstated. You must ask for an Administrative Review within 90 days of losing coverage. To ask for an Administrative Review, write to: CalPERS Health Account Services P.O. Box Sacramento, CA Once we have all of your information, we will review your request. We will tell you within 60 days if your coverage will be reinstated. If your coverage is not reinstated, we will tell you why. Filing a Grievance If you feel your health plan has not helped you appropriately, you have a legal right to file a written grievance with them to resolve an issue, complaint, or disagreement. Refer to your health plan s Evidence of Coverage booklet for more information about your plan s grievance process. Contact your health plan for a copy of the Evidence of Coverage booklet. 32 CalPERS Medicare Enrollment Guide

35 Appealing a Decision If you receive a written response about a grievance you filed and you are not satisfied with the decision, you may also appeal your plan s decision as follows: Members in a Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) Plan The California Department of Managed Health Care (DMHC) regulates all HMOs in California. If you are an HMO or EPO health plan enrollee, and you have filed a grievance and are dissatisfied with your HMO or EPO s final decision, you should contact the DMHC HMO Consumer Help Center at (888) or TTY (877) to register your complaint. You also should request assistance through DMHC s website at You may contact DMHC if the matter is not resolved within 30 days from the time your grievance was received by your health plan. Contact them immediately if the matter is urgent. If you have filed a grievance and are dissatisfied with your HMO or EPO s final decision regarding your eligibility for health benefits or limits of coverage under the plan, you may contact CalPERS for assistance. Members in a Preferred Provider Organization (PPO) Plan If you are a PPO health plan enrollee, and you have filed a grievance and are dissatisfied with your PPO s final decision, you may contact CalPERS at 888 CalPERS (or ) for assistance. Binding Arbitration Binding arbitration is a method used by some health plans to resolve conflicts. It requires you to agree in advance that any claims or disagreements will be settled through a neutral, legally binding resolution, replacing court or jury trials. In some instances, you can choose to appeal to CalPERS rather than go through binding arbitration. If your plan requires binding arbitration, the process will be described in your plan s Evidence of Coverage booklet, which you can obtain from your health plan. CalPERS Medicare Enrollment Guide 33

36 CalPERS Notice of Agreement for Arbitration Enrolling in certain health benefit plans constitutes your agreement that any dispute(s) you have with the plan including medical malpractice, that is, whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, as well as any dispute(s) relating to the delivery of service under the plan will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. By enrolling in one of these plans, you are giving up your constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Please refer to the health plan s Evidence of Coverage booklet for details. The California Patient s Guide The California Patient s Guide: Your Health Care Rights and Remedies informs you of your rights to receive quality health care and what steps you can take if you encounter problems. The full text of the guide is available at or you can request a copy by calling the DMHC HMO Consumer Help Center at (888) CalPERS Medicare Enrollment Guide

37 Patient Bill of Rights As a member of the CalPERS Health Program, you have important rights. These rights protect your privacy, your access to quality health care, and your right to participate fully in medical decisions affecting you and your family. How and Where to Get Help If you have a concern about your rights and health care services, we urge you to first discuss it with your physician, hospital, or other provider, as appropriate. Many complaints can be resolved at this level because your health plan wants satisfied customers. If you still have concerns, you may have the right to appeal the health plan s decision directly to CalPERS or, in many health plans, through the grievance procedure. Consult your Evidence of Coverage booklet for information on the benefits covered or your appeal rights. You can contact CalPERS at 888 CalPERS (or ) for further information. As a patient and a CalPERS member, you have the right to: Be treated with courtesy and respect Receive health care without discrimination Have confidential communication about your health Have your medical record or information about your health disclosed only with your written permission Access and copy your medical record Have no restrictions placed on your doctor s ability to inform you about your health status and all treatment options Be given suffcient information to make an informed decision about any medical treatment or procedure, including its risks and benefits Refuse any treatment Designate a surrogate to make your health care decisions if you are incapacitated CalPERS Medicare Enrollment Guide 35

38 Access quality medical care, including specialist and urgent care services, when medically necessary and covered by your health plan Access emergency services when you, as a prudent layperson, could expect the absence of immediate medical attention would result in serious jeopardy to you Participate in an independent, external medical review when covered health care services are denied, delayed, or limited on the basis that the service was not medically necessary or appropriate, after the health plan s internal grievance process has been exhausted Discuss the costs of your care in advance with your provider Get a detailed, written explanation if payment or services are denied or reduced Have your complaints resolved in a fair and timely manner and have them expedited when a medical condition requires treatment You can help protect your rights by doing the following: Express your health care needs clearly Build mutual trust and cooperation with your providers Give relevant information to your health care provider about your health history, condition, and all medications you use Contact your providers promptly when health problems occur Ask questions if you don t understand a medical condition or treatment Be on time for appointments Notify providers in advance if you can t keep your health care appointment Adopt a healthy lifestyle and use preventive medicine, including appropriate screenings and immunizations Familiarize yourself with your health benefits and any exclusions, deductibles, co-payments, and treatment costs Understand that cost controls, when reasonable, help keep good health care affordable 36 CalPERS Medicare Enrollment Guide

39 CalPERS Notice of Privacy Practices Effective Date: April 14, 2011 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. If you have any questions about this notice, please contact the Health Insurance Portability and Accountability Act (HIPAA) Administrator at 888 CalPERS (or ). Why We Ask for Information About You The Information Practices Act of 1977 and the Federal Privacy Act require CalPERS to provide the following information to individuals who are asked to supply information. The information requested is collected pursuant to the Government Code (Section 20000, et seq.) and will be used for administration of the Board s duties under the Public Employees Retirement Law, the Social Security Act, and the Public Employees Medical and Hospital Care Act, as the case may be. Submission of the requested information is mandatory. Failure to supply the information may result in CalPERS being unable to perform its functions regarding your status. Portions of this information may be transferred to other governmental agencies (such as your employer), physicians, and insurance carriers but only in strict accordance with current statutes regarding confidentiality. You have the right to review your CalPERS membership file. For questions concerning your rights under the Information Practices Act of 1977, please contact the CalPERS Customer Contact Center at 888 CalPERS (or ). How We Use Your Social Security Number Section 7(b) of the Privacy Act of 1974 (Public Law ) requires that any federal, State, or local governmental agency which requests an individual to disclose a Social Security number shall inform that individual whether that disclosure is mandatory or voluntary, by which statutory or other authority such number is solicited, and what uses will be made of it. CalPERS Medicare Enrollment Guide 37

40 Section 111 of Public Law requires group health plans to collect and provide member Social Security numbers for the coordination of federal and State benefits. Furthermore, the CalPERS Health Program requires each enrollee s Social Security number for identification purposes and to verify eligibility for benefits. The CalPERS Health Program uses Social Security numbers for the following purposes: Enrollee identification for eligibility processing and verification Payroll deduction and State contribution for State employees Billing of public agencies for employee and employer contributions Reports to CalPERS and other State agencies Coordination of benefits among health plans Resolution of member appeals/complaints/grievances with health plans How We Safeguard Your Protected Health Information We understand that protected health information about you is personal and CalPERS is committed to safeguarding protected health information, which is in our possession. This notice applies to all of the records of your health plan participation generated by CalPERS. The participating health plan in which you are enrolled may have different policies or notices regarding its use and disclosure of your protected health information. The remainder of this notice will tell you about the ways that we may use and disclose protected health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of protected health information. The Federal Health Insurance Portability and Accountability Act Privacy Regulations (Title 45, Code of Federal Regulations, sections , et seq.) require us to: Make sure protected health information that identifies you is kept private Give you this notice of our legal duties and privacy practices with respect to your protected health information Follow the terms of the notice that is currently in effect 38 CalPERS Medicare Enrollment Guide

41 How We May Use and Disclose Your Protected Health Information The following categories describe different ways that we may use and disclose protected health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories. Health Care Operations. We may use and disclose protected health information about you for CalPERS health benefits operations. These uses and disclosures are necessary to run the CalPERS health benefits program and make sure that all of our enrollees receive quality care. For example, we may use and disclose protected health information about you to confirm your eligibility and to enroll you in the participating health plan that you select, to evaluate the performance of the health plan in which you are enrolled, for coordination of benefits among health plans, or to resolve an appeal, complaint, or grievance with the health plan. We may also combine protected health information about many CalPERS health benefits enrollees to evaluate health plan performance, to assist in rate setting, to measure quality of care provided or for other health care operations. In some cases, we may obtain protected health information about you from a participating health plan, provider, or third-party administrator for certain health care operations. If the protected health information received from others is part of our health care operations, the uses and disclosures would be in accordance with this guideline. Health-Related Benefits and Services. We may use and disclose protected health information to tell you about health-related benefits or services, such as treatment alternatives, disease management or wellness programs that may be of interest to you. Named Insured. If you are enrolled in the CalPERS health benefit program as a dependent, we may release protected health information about you to the named insured. CalPERS Medicare Enrollment Guide 39

42 As Required By Law. We will disclose protected health information about you when required to do so by federal, state, or local law or regulation. To Avert a Serious Threat to Health or Safety. We may use and disclose protected health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. Special Situations Workers Compensation. We may release protected health information about you for workers compensation or similar programs. These programs provide benefits for work-related injuries or illness. Health Oversight Activities. We may disclose protected health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if you have been given proper notice and an opportunity to object. Law Enforcement. We may release protected health information if asked to do so by a law enforcement offcial in response to a court order, subpoena, warrant, summons, or similar process. National Security and Intelligence Activities. We may release protected health information about you to authorized federal offcials for intelligence, counterintelligence, and other national security activities authorized by law. 40 CalPERS Medicare Enrollment Guide

43 Protective Services for the President and Others. We may disclose protected health information about you to authorized federal or state offcials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement offcial, we may release protected health information about you to the correctional institution or law enforcement offcial. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. Rights Regarding Your Protected Health Information You have the following rights regarding protected health information we maintain about you: Right to Inspect and Copy. You have the right to inspect and copy protected health information about you that is maintained by the CalPERS Health Program. In most cases, this consists solely of information concerning your health plan enrollment. In some cases, it may also include information that you have provided to CalPERS to assist with coordination of benefits among health plans or to resolve an appeal, complaint, or grievance against the health plan in which you are enrolled. To inspect and copy protected health information about you that is maintained by the CalPERS Health Program, you must submit your request in writing to the HIPAA Administrator at P.O. Box , Sacramento, CA If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to the protected health information, you may request that the denial be reviewed. A licensed health care professional chosen by CalPERS will review your request and CalPERS Medicare Enrollment Guide 41

44 the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review. Right to Amend. If you feel the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the CalPERS Health Program. To request an amendment, your request must be made in writing and submitted to the HIPAA Administrator at P.O. Box , Sacramento, CA In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: Was not created by us, unless the person or entity that created the information is no longer available to make the amendment; Is not part of the protected health information kept by or for CalPERS; Is not part of the information which you would be permitted to inspect and copy; or Is accurate and complete. Right to an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a list of the disclosures we made of the protected health information about you. To request this list or accounting of disclosures, you must submit your request in writing to the HIPAA Administrator at P.O. Box , Sacramento, CA Your request must state a time period, which may not be longer than six years and may not include dates before April 14, Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the costs 42 CalPERS Medicare Enrollment Guide

45 involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a surgery you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to the HIPAA Administrator at P.O. Box , Sacramento, CA In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail to a specific address. To request confidential communications, you must make your request in writing to the HIPAA Administrator at P.O. Box , Sacramento, CA We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still CalPERS Medicare Enrollment Guide 43

46 entitled to a paper copy of this notice. To obtain a paper copy of this notice contact the HIPAA Administrator at 888 CalPERS (or ). Changes to This Notice We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at CalPERS and on the CalPERS website at The notice will contain on the first page, in the top right-hand corner, the effective date. Complaints If you believe your privacy rights have been violated, you may file a complaint with CalPERS or with the Secretary of the California Health and Human Services Agency. To file a complaint with CalPERS, contact the HIPAA Administrator at 888 CalPERS (or ). All complaints must be submitted in writing. You will not be retaliated against for filing a complaint. Other Uses of Protected Health Information Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of your participation in the CalPERS health benefits program. 44 CalPERS Medicare Enrollment Guide

47 Definition of Terms CalPERS Basic Health Plan A CalPERS Basic plan provides health benefits coverage to members who are under age 65 or who are over age 65 and still working. Members who are 65 years of age or older and not eligible for Medicare Part A at no cost may also be eligible to enroll in a Basic health plan. CalPERS Medicare Health Plan A CalPERS Medicare health plan requires Medicare to assume the role as primary payer for health care costs. This coordination of benefits between Medicare and your CalPERS Medicare plan lowers the costs of your health premiums and provides some coverage beyond Medicare. Centers for Medicare & Medicaid Services (CMS) A federal agency created in 1977 under the Department of Health and Human Services, CMS is responsible for administering the Medicare and Medicaid programs and ensuring that Medicare and Medicaid beneficiaries have access to high-quality medical care in appropriate settings. Consolidated Omnibus Budget Reconciliation Act (COBRA) When health benefits would cease, COBRA allows continuation of health coverage for a limited time under certain circumstances as a result of job loss (for reasons other than gross misconduct), reduction in hours worked, death, divorce, and other life events. You should contact CMS with questions about the Medicare program and benefits. CalPERS Medicare Enrollment Guide 45

48 Co-payment The amount you pay for a doctor visit or for receiving a covered service or prescription. Deductible The amount you must pay for health care before the plan starts to pay. Dependent A family member who meets the specific eligibility criteria for coverage in the CalPERS Health Program. Disenrolling The steps you follow to end coverage with your current HMO Medicare Managed Care health plan so that you may join a new health plan. Employer Contribution The amount your current or former employer contributes towards the cost of your health premium. Employer Group Health Plan (EGHP) Health coverage you receive through either your own or your spouse s active employment. Generally, EGHP coverage is your primary coverage. Emergency Services Medical services to treat an injury or illness that could result in serious harm if you don t get care right away. Faculty Early Retirement Program (FERP) A program for California State University (CSU) retirees who continue to work for CSU after retirement. Health Insurance Portability & Accountability Act (HIPAA) This federal law protects health insurance coverage for workers and their families when they change or lose their jobs. It also includes provisions for national standards to protect the privacy of personal health information. 46 CalPERS Medicare Enrollment Guide

49 Non-Participating Provider Non-preferred providers that have not contracted with the health plan. Out-of-Pocket Costs Generally refers to the actual costs individuals pay to receive health care. These costs are the total of the premium (minus any employer contribution) plus any additional costs such as co-payments and deductibles. Open Enrollment Period A specific period of time, as determined by the CalPERS Board of Administration, when you can enroll in or change health plans or add eligible family members who are not currently enrolled in the CalPERS Health Program. Preferred Provider This is a provider that participates in a preferred provider network. You will pay less to visit a preferred provider. Premium The monthly amount charged by a health plan to provide health benefits coverage. Employee costs for premiums may be reduced by employer contributions. Primary Care Provider (PCP) The doctor who works with you and other doctors to provide, prescribe, approve, and coordinate all your medical care and treatment (also referred to by some health plans as Personal Physician ). Retiree A person who has retired within 120 days of separation from employment with the State or a contracting agency and who receives a retirement allowance from the retirement system provided by the employer. CalPERS Medicare Enrollment Guide 47

50 Service Area The geographic area in which your health plan provides coverage. You must reside or work in the health plan s service area to enroll in and remain enrolled in a plan. For some plans, the Medicare service area may not be identical to the Basic service area. Specialist A doctor who has special training in a specific kind of medical care, for example, cardiology (heart), neurology (nervous system), or oncology (cancer). Social Security Administration (SSA) An agency under the Executive Branch of the U.S. Government, the SSA is responsible for delivery of Social Security services including Medicare. The SSA is also responsible for determining Medicare eligibility and premiums, and for Medicare enrollment. You should contact the SSA about Medicare enrollment and eligibility issues, name or address changes, questions about premiums, and to report a death. Urgently Needed Services A non-emergency situation when you need to see a doctor, but are away from your health plan s service area. See your health plan s Evidence of Coverage booklet for more details. 48 CalPERS Medicare Enrollment Guide

51 CalPERS Medicare Enrollment Guide 49

52 CalPERS Health Benefits Program P.O. Box Sacramento, CA CalPERS (or ) HBD 65 Produced by CalPERS External Affairs, Offce of Public Affairs August